2016 Summer Institute
Student Application
“I learned to
never give
up.”
“I got out of my little
bubble and got to
meet and trust other
people.”
“…I now feel I have selfdiscipline and I am more
self-motivated.”
5th Annual
Summer Institute
Program
Become a part of our
2016 Summer Institute family!
What is the Summer Institute program at Diné College?
The Summer Institute is a two (2) week program to help incoming college freshmen students
improve their Accuplacer placement test scores in math, reading & writing. This program also
prepares incoming Diné College students to be college ready.
Diné College | 2016 Summer Institute Application 1
2016 Summer Institute
Student Application
Program Dates:
JULY 09-22, 2016
RESIDENTIAL SUMMER BRIDGE PROGRAM AT DC TSAILE CAMPUS
The Summer Institute is an intense program with a rigorous schedule, for this
reason it requires 100% participation throughout the entire duration of the
program.
Student Eligibility
You must meet ALL these requirements to apply:
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Admitted to Diné College and have a Diné College student ID number
An incoming college freshman (You have NEVER attended a
college/university)
Plan to register and enroll at Diné College for the Fall 2016 semester
Have taken the Accuplacer placement test and entered into 1 or more precollege courses in reading, writing, & math (MTH 100 or lower, FST,
ENG100A, ENG100B courses)
Dual Credit Students: All are invited to apply but must meet all student
eligibility requirements above
Cost
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PART 1
Benefits
Tuition, supplies, room & board are
fully covered by Diné College’s
Title III grant under Student Affairs.
Out-of-pocket costs include travel
to and from the program, and
incidental expenses (extra
spending money, hygiene
products, etc.).
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We look forward to
your application!
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An opportunity to receive three (3)
college elective credits
Re-take the Accuplacer placement
test to improve your reading,
writing and/or math scores
Save time & money
Receive an early introduction to
college life
Obtain College survival skills
Build a close-knit community with
other Diné College freshmen
Be a part of the First Year
Experience Program at Diné
College
Diné College | 2016 Summer Institute Application 2
2016 Summer Institute
Student Application
Student Information
PART 2
Date of Application:_________________________
First Name
T-Shirt Size:_____________________
MI
Diné College Student ID#
Tribal Affiliation
Last Name
Gender
Date of Birth
Primary Language Spoken
Email Address
Mailing Address
City/Town
State
Zip Code
Home/Cell Phone Number
High School Name
Graduation Date
1. Are you a Dual Credit Student with Diné College? (please circle)
Yes or
No
If Yes, last semester attended?____________
2. Did you receive a High School Equivalency Certification/Diploma? (i.e. TASC, GED, HSE or
HiSet)? (please circle)
YES
or
NO
If so, from what state? ___________What year?_______________
3. Have you ever been convicted of a felony?
(please circle)
Yes or No
If YES, please provide specific information (dates, charge, and disposition):_______________________________
______________________________________________________________________________________________
4. Have you been convicted of any misdemeanor(s) in any Courts? (please circle) Yes or No
If YES, provide specific information (date, charge, and disposition): ___________________________________
______________________________________________________________________________________________
5. How did you hear or learn about the Summer Institute program (i.e. Flyer, College 101 day, Radio,
etc…)_______________________________________________________________________________________
6. Do you know any other person who will be applying to the Summer Institute program?
(please circle) Yes or No
If YES, what is your relation (i.e. friend, cousin, sister, brother, etc…)? ___________________________________
Please also provide their first and last name:_____________________________________________________________
Parent/Guardian Information
Name of parent(s) or guardian(s):
Mailing Address
City/Town
State
Home/Cell Phone Number
Email Address
Zip Code
Diné College | 2016 Summer Institute Application 3
2016 Summer Institute
Student Application
Student Medical Information
PART 3
1. Do you have any documented disability and/or any medical conditions? (please circle) Yes or No
If Yes, please explain:___________________________________________________________________________
_________________________________________________________________________________________________
2. List any allergies to food or medication:______________________________________________________
________________________________________________________________________________________________
3. List all medication(s) you are taking at the present time:_______________________________________
________________________________________________________________________________________________
4. What are the side effects of the medication(s) you are taking? (i.e. drowsiness):
Please explain:_________________________________________________________________________________
5. List any other physical challenges or mental health concerns we should be aware of:
____________________________________________________________________________________________
6. Would you require additional accommodations inside the classroom?
(please circle)
Yes or No
(i.e. using a computer, a communication device, testing time, or etc…)
If Yes, please explain:__________________________________________________________________________
_______________________________________________________________________________________________
7. Would you require additional accommodations outside the classroom? (i.e. accessibility)
(please circle) Yes or No
If YES, please explain:__________________________________________________________________________
_______________________________________________________________________________________________
8. Are you currently receiving counseling services? (please circle) Yes or No
If YES, is the student under doctors’ care?
(please circle)
Yes or No
The Summer Institute does not discriminate on the basis of race, color, age, ethnicity, religion, national origin, pregnancy,
sexual orientation, gender identity, genetic information, sex, marital status, disability, or status as a U.S. veteran.
Diné College | 2016 Summer Institute Application 4
2016 Summer Institute
Student Application
Student Essays
PART 4
The Summer Institute Committee is interested in knowing more about you as
an individual. The questions below provide you with an opportunity to tell us
about yourself and your future goals.
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It is preferred you TYPE your answers
No access to a computer? Write your responses legibly on a separate sheet of
paper, so that the committee can read your responses clearly.
ESSAY QUESTIONS
 Each question needs to be answered thoroughly
 Answers for each question should be at least one paragraph (5 - 8
sentences), but should not exceed two paragraphs in length
 Write your first and last name, including your Diné College student ID# on
each of your pages
1) Why do you want to participate in the Summer Institute
Program?
2) List three (3) goals you have for your future and how you plan
to accomplish them?
3) Why is it important for you to attend college?
4) What motivates you to succeed in life?
5) What has been the most challenging experience for you this past
year and how did you overcome it?
Diné College | 2016 Summer Institute Application 5
2016 Summer Institute
Student Application
Student Agreement Form
PART 5
We are excited that you have decided to apply for the 2016 Summer Institute at Diné
College. Please read over the following information.
CHECK IN: SATURDAY, JULY 09, 2016 @ 2:00 P.M.
CHECK OUT: FRIDAY, JULY 22, 2016 @ 2:00 P.M.
All student participants will be required to reside in the Residence Hall for the entire
duration of the program. Due to the Summer Institute’s rigorous schedule NO exceptions
will be made for students to arrive late or leave early from the program.
If selected as a 2016 Summer Institute student, I agree to comply with the following (please
sign your initials next to each statement):
______ I will be in attendance for the ENTIRE duration of the program.
______ I will be committed and present at all Summer Institute workshops, classes,
meetings and activities.
______ I will demonstrate good behavior and follow the Diné College Student Code of
Conduct throughout the duration of the 2016 Summer Institute Program.
______ I will not use, sell, possess or distribute any illicit drugs, alcohol, or weapons while
participating in the 2016 Summer Institute Program.
______ I understand if I violate any rules, expectations and/or the Student Code of Conduct,
consequences will be enforced which can also affect my Fall 2016 enrollment,
including, but not limited to, a repayment of the program expenses, estimated at
$1,500 per student.
______ I will make sure to have a positive attitude, so that all Summer Institute participants
have an enjoyable experience.
By signing below I agree that all information provided is correct to the best of my knowledge. In
addition, as a potential 2016 Summer Institute student I agree to comply with all rules and
regulations.
_______________________________
_____________________________________________
Student Participant - Print Name
Student Participant - Signature
Date
_________________________________________________________________________________
Parent/Guardian Signature (IF STUDENT IS UNDER 18 YEARS OF AGE)
Diné College | 2016 Summer Institute Application 6
Date
2016 Summer Institute
Student Application
Application Checklist
Go through the following checklist to insure that you have fully completed the Summer
Institute application.
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Read PART 1 to confirm that you meet the eligibility requirements
Mail or drop off the following materials to the address below:
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PART 2 - the Student & Parent/Guardian Information
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PART 5 - the Student Agreement Form
PART 3 - the Student Medical Information
PART 4 - your answers to the 5 Short Answer Essays
o Put name and Diné College student ID# on all essay pages
Attach copy of your Accuplacer placement test scores or if you need
assistance in obtaining one call Diné College Student Success Center at
928.724.6855
SPACE IS LIMITED! FIRST COME, FIRST SERVE…
Application Due Date:
Monday, June 27, 2016
Mail ALL Application Materials to:
Barbara Harvey – Administrative Assistant
Division of Student Affairs-Title III
PO Box C11
Tsaile, AZ 86556
Questions? Contact:
Student Success Center
928.724.6855
bjharvey@dinecollege.edu
Additional Information:
http://www.dinecollege.edu/summer-institute/index.php
Diné College | 2016 Summer Institute Application 7